Managing Gout in Primary Care

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MICHAEL H.

FACULTY

FACULTY

Pillinger, MD

Professor Department of Medicine Department of Biochemistry and Molecular Pharmacology New York University School of Medicine Director of Rheumatology VA New York Harbor Healthcare System New York, New York Dr. Michael Pillinger is Professor of Medicine and Professor of Biochemistry and Molecular Pharmacology at New York University School of Medicine, where he directs the Rheumatology Fellowship Training Program as well as the Masters of Science in Clinical Investigation Program. A longtime investigator in inflammation and crystal diseases including gout, he is the author of more than 100 original research articles, reviews, and book chapters.

PAUL P.

Doghramji, MD, FAAFP Family Physician Collegeville Family Practice Medical Director of Health Services Ursinus College Collegeville, Pennsylvania Dr. Paul Doghramji is senior family practice physician at Collegeville Family Practice, and the Medical Director of health services at Ursinus College, both in Collegeville, Pennsylvania. He is also an attending physician in family practice at Pottstown Memorial Medical Center in Pottstown, Pennsylvania. He is past and present co-chair of the National Sleep Foundation’s Sleep and Health Safety Course, and has devoted almost 3 decades to sleep science and education.

Dr. Doghramji received his medical degree from Jefferson Medical College in Philadelphia, Pennsylvania, in 1982. He then completed his residency in family practice at Chestnut Hill Hospital in 1985. A member and fellow of the American Academy of Family Physicians and the Pennsylvania Academy of Family Physicians, he has received the American Medical Association’s Physician Recognition Award 8 times.

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FACULTY

Dr. Doghramji has published over 50 papers in peer-reviewed journals, including The American Journal of Medicine, Current Medical Research and Opinion, and Postgraduate Medicine. He is also coauthor of the textbook, Clinical Management of Insomnia.

N. LAWRENCE

Edwards, MD, MACP, FACR Professor of Medicine Division of Rheumatology and Clinical Immunology Program Director, Internal Medicine Residency Vice Chair, Graduate Medical Education University of Florida Gainesville, Florida Dr. N. Lawrence Edwards is Professor of Medicine, Division of Rheumatology and Clinical Immunology, as well as Program Director of Internal Medicine Residency and Vice Chair of the Department of Medicine at the University of Florida in Gainesville. Dr. Edwards obtained his undergraduate degree from the University of Notre Dame and his medical degree from the University of Miami School of Medicine. He completed his training in rheumatology at the Rackham Arthritis Research Center and the Clinical Research Center, University of Michigan in Ann Arbor, where he remained on the faculty as Director of Education and Training in the Division of Rheumatology. In 1983 he transferred to the University of Florida, where he served as Chief of the Division of Rheumatology and Clinical Immunology and Rheumatology Program Director for 15 years. He has held his current positions for the past 12 years.

Dr. Edwards is an active member of many professional organizations, including the American College of Rheumatology, the College of Physicians, and the Association of Program Directors in Internal Medicine. He is on the Executive Board of the Florida Chapter of the American College of Physicians, and is the Co-chair of the Gout Interest Group for OMERACT (Outcomes Measures in Rheumatology), and the Chairman and Chief Executive Officer of the Gout and Uric Acid Education Society, a nonprofit, patient education organization. A Master in the American College of Physicians, he has authored more than 150 scientific articles, book chapters, and reviews on the topics of hyperuricemia, gout, and purine metabolism.

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THEODORE R.

FACULTY

Fields, MD, FACP Professor of Clinical Medicine Weill Cornell Medical College Director, Rheumatology Faculty Practice Plan Hospital for Special Surgery New York, New York Dr. Theodore R. Fields is Director of the Rheumatology Faculty Practice Plan at the Hospital for Special Surgery in New York. He is a Professor of Clinical Medicine at Weill Cornell Medical College.

Dr. Fields has a special clinical and research interest in gout that dates back to basic research on uric acid crystals during his fellowship and encompasses a more recent clinical study of unusual presentations of gout and on gout treatment. He is presently involved in an investigation of a team approach to gout management, including the roles of rheumatologist, nurse practitioner, registered nurse, pharmacist, and social worker. He has also been involved in the study of an education and support program for patients with early rheumatoid arthritis. At the 2012, 2013, and 2014 American College of Rheumatology meetings, he presented a “Meet the Professor” session on “Diagnosis and Management of Gout.”

ROBERT T.

Keenan, MD, MPH Assistant Professor of Medicine Director, Duke Gout and Crystal Arthropathy Clinic Duke University School of Medicine Durham, North Carolina Dr. Robert T. Keenan is an Assistant Professor of Medicine at Duke University School of Medicine in the Division of Rheumatology and Immunology. He is the founding director of the Gout and Crystal Arthropathy Clinic at Duke University as well as head of 2 infusion centers. Currently involved in clinical outcomes research focusing on crystal arthropathy and inflammatory eye conditions, Dr. Keenan has authored multiple book chapters and peer-reviewed articles.

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BRIAN D. FACULTY

Koffman, MDCM, DCFP, FCFP, DABFP, MSEd Medical Director CLL Society Inc. Claremont, California Dr. Brian Koffman earned his medical degree from McGill University and completed his Family Practice residency at the University of Western Ontario and his Psychiatry Fellowship at McMaster University. Dr. Koffman taught at the University of Waterloo and is a retired Clinical Professor at the University of Southern California, Keck School of Medicine, where he also completed his Masters of Science in Medical Education. His primary care practice is with St. Jude Heritage Medical Group, Diamond Bar California. As the former medical director of Primary Care Network (PCN), he has been involved in providing CME for community physicians in pain management, irritable bowel syndrome, blood cancers, sleep disorders, gout, migraine, and many other practical primary care topics. As a doctor turned patient, his popular blog (http://bkoffman.blogspot.com) and the wide scope of his volunteer efforts in other community and online patient advocacy and education has added an increasingly meaningful new dimension to his life’s work. He is the founder and volunteer medical director of the nonprofit 501c3 CLL Society (http://cllsociety.org), which is dedicated to the unmet needs of those with chronic lymphocytic leukemia and related blood cancers. He is licensed and Board Certified in Family Practice in both the United States and Canada.

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EDUCATIONAL OBJECTIVES •• Describe the pathophysiologic underpinnings of gout, with a focus on urate metabolism and excretion •• Differentially diagnose gout based on hyperuricemia, joint assessment, podagra, and relevant risk factors •• Discuss current and emerging treatment strategies that can reduce hyperuricemia and risks of acute gout attacks •• Tailor treatment regimens for patients with gout based on disease severity, renal function, therapeutic response, and comorbid conditions

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•• Engage patients in open dialogue about gout as a chronic disease, treatment expectations and options, and the importance of treatment adherence

FACULTY FINANCIAL DISCLOSURE STATEMENTS The presenting faculty reported the following: Michael H. Pillinger, MD, is a consultant for AstraZeneca and Crealta Pharmaceuticals, Inc. Dr. Pillinger has also received research support from Takeda Pharmaceutical Company Ltd. Paul P. Doghramji, MD, FAAFP, is a member of the Advisory Board for AstraZeneca, Iroko Pharmaceuticals, LLC, and Merck & Co., Inc.; the Speakers Bureau for AstraZeneca, Merck & Co., Inc., Takeda Pharmaceutical Company Ltd. and Teva Pharmaceuticals. Dr. Doghramji has also received fees from Pfizer Inc. N. Lawrence Edwards, MD, MACP, FACR, is a consultant for AstraZeneca, Crealta Pharmaceuticals, Inc., CymaBay Therapeutics Inc., and Takeda Pharmaceutical Company Ltd. Theodore R. Fields, MD, FACP, is a member of the Advisory Board for AstraZeneca, Crealta Pharmaceuticals, Inc., and Takeda Pharmaceutical Company Ltd.; the Speakers Bureau for Takeda Pharmaceutical Company Ltd. Robert T. Keenan, MD, MPH, is a member of the Advisory Board for AstraZeneca and Crealta Pharmaceuticals, Inc Brian D. Koffman, MDCM, DCFP, FCFP, DABFP, MSEd, is a member of the Advisory Board and Speakers Bureau for AstraZeneca. Dr. Koffman has ownership interest in AbbVie Inc., Gilead Sciences, Inc., Infinity Pharmaceuticals, Inc., TG Therapeutics, Inc., Enanta Pharmaceuticals, Inc., and Johnson & Johnson.

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EDUCATION PARTNER FINANCIAL DISCLOSURE STATEMENTS The content collaborators at Integritas Communications have reported the following: Jim Kappler, PhD, has nothing to disclose.

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PMICME CLINICAL STAFF AND TUFTS HEALTH CARE INSTITUTE EXPERT REVIEWER FINANCIAL DISCLOSURE As a continuing medical education provider accredited by the ACCME, it is the policy of pmiCME to require any individual in a position to influence educational content to disclose the existence of any financial interest or other personal relationship with the manufacturer(s) of any commercial product(s). pmiCME clinical staff and Tufts Health Care Institute expert content reviewers have provided financial disclosure and have no conflicts of interest to resolve for each of the sessions related to this activity.

CONFLICT OF INTEREST RESOLUTION STATEMENT pmiCME requires all individuals in a position to influence educational content for pmiCME-certified CME activities to disclose relevant personal financial relationship(s) with commercial interests prior to contributing to the activity. pmiCME assesses disclosed relationships and follows a defined process to resolve real or implied conflicts to ensure, to the best of our ability, that all educational content is free of commercial bias. Financial disclosures are listed in this program and will also be announced prior to the start of each presentation and posted on www.pri-med.com.

OFF-LABEL/INVESTIGATIONAL DISCLOSURES During the course of their presentations, the faculty may mention uses of products that have not been approved in the United States for the indication(s) being discussed. All presenters are instructed to notify participants when they are discussing unapproved uses or investigational agents. In addition, specific slides will include notation of the off-label use or investigational agent being discussed. Views presented during this program related to unapproved uses of products are solely those of the presenter(s) and are not endorsed by pmiCME, DBC Pri-Med, LLC, or ACP.

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ACCREDITATION STATEMENT pmiCME is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

DESIGNATION STATEMENT

ACKNOWLEDGMENT OF COMMERCIAL SUPPORT This activity is supported by an educational grant from AstraZeneca.

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pmiCME designates this live activity for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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GUIDELINES »» 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia.

Khanna D, et al. Arthritis Care Res (Hoboken). 2012;64(10):1431-1446. http://onlinelibrary.wiley.com/doi/10.1002/acr.21772/epdf

»» 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis.

Khanna D, et al. Arthritis Care Res (Hoboken). 2012;64(10):1447-1461. http://onlinelibrary.wiley.com/doi/10.1002/acr.21773/epdf

»» Evolution of management of gout: a comparison of recent guidelines.

Khanna PP, FitzGerald J. Curr Opin Rheumatol. 2015;27(2):139-146. http://www.ncbi.nlm.nih.gov/pubmed/25611299

»» 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.

Neogi T, Jansen TL, Dalbeth N, et al. Ann Rheum Dis. 2015;74(10):1789-1798. http://www.ncbi.nlm.nih.gov/pubmed/26359487

»» What Is Gout? Fast Facts: An Easy-to-Read Series of Publications for the Public A brochure in simplified language from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health http://www.niams.nih.gov/health_info/gout/gout_ff.pdf

»» Gout Patient brochure from the American College of Rheumatology http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Gout

»» Gout Education for Patients Patient information from the Gout & Uric Acid Education Society http://gouteducation.org/patient/education/

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RESOURCE CENTER

EDUCATIONAL MATERIAL for PATIENTS and THEIR FAMILIES

SUGGESTED READING »» The emerging role of biotechnological drugs in the treatment of gout.

Cavagna L, Taylor WJ. BioMed Res Int. 2014. doi: 10.1155/2014/264859. Epub 2014 Apr 16.

»» Imaging in gout: a review of the recent developments.

Chowalloor PV, et al. Ther Adv Musculoskelet Dis. 2014;6(4):131-143.

»» New medications in development for the treatment of hyperuricemia of gout.

Diaz-Torné C, et al. Curr Opin Rheumatol. 2015;27(2):164-169.

»» Pharmacodynamic, pharmacokinetic and tolerability evaluation of concomitant administration of lesinurad and febuxostat in gout patients with hyperuricaemia.

Fleischmann R, et al. Rheumatology. 2014;53(12):2167-2174.

»» The pathophysiology of hyperuricaemia and its possible relationship to cardiovascular disease, morbidity and mortality.

Gustafsson D, Unwin R. BMC Nephrology. 2013;14:164.

»» Emerging therapies for gout.

Edwards NL, So A. Rheum Dis Clin North Am. 2014;40(2):375-387.

»» The association of gout with socioeconomic status in primary care: a crosssectional observational study.

Hayward RA, et al. Rheumatology (Oxford). 2013;52(11):2004-2008.

»» The crystallization of monosodium urate.

Martillo MA, et al. Curr Rheumatol Rep. 2014;16(2):400.doi:10.1007/s11926-013-0400-9.

»» Racial and gender disparities in patients with gout.

Singh JA. Curr Rheumatol Rep. 2013;15(2):307.doi:10.1007/s11926-012-0307-x.

RESOURCE CENTER

»» Gout and its comorbidities: implications for therapy.

Stamp LK, Chapman PT. Rheumatology (Oxford). 2013;52(1):34-44.

»» Improved health-related quality of life and physical function in patients with refractory chronic gout following treatment with pegloticase: evidence from phase III randomized controlled trials.

Strand V, et al. J Rheumatol. 2012;39(7):1450-1457.

»» Recent advances in management of gout.

Suresh E, Das P. QJM. 2012;105(5):407-417.

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